OncOlOgy nursing FOrum – vOl 35, nO 6, 2008
breast cancer were the largest group of survivors, compris-
ing 22% of the population. The survivors remain largely
understudied and lost to follow-up (Hewitt, greenfield, &
Three trends emerged from Hewitt et al.’s (2006) report:
cancer can become a chronic condition that must be managed
for a lifetime; although life is preserved, many survivors suffer
n 2006, a report on the quality of life (QOl) of cancer
survivors revealed a population of more than 10 million
survivors in the united states. Women with a history of
The Experience of Imagery as a Post-Treatment
Intervention in Patients With Breast Cancer:
Program, Process, and Patient Recommendations
Lyn Freeman, PhD, Lorenzo Cohen, PhD, Mary Stewart, MD,
Rebecca White, MD, Judith Link, RN, J. Lynn Palmer, PhD,
Derek Welton, Lisa McBride, BS, and Carl M. Hild, PhD
This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints,
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Purpose/Objectives: To better understand the common themes of
women participating in an imagery program designed to improve quality
of life (QOL).
Research Approach: Qualitative.
Setting: Classroom setting at Alaska Regional Hospital in Anchorage.
Participants: 10 women with a confirmed diagnosis of breast cancer
who had completed conventional care participated in a six-class, eight-
week-long imagery program titled Envision the Rhythms of Life© (ERL).
Methodologic Approach: Focus group audio recordings and notes
were interpreted with the Krueger focus group method and confirmed by
an outside evaluator.
Main Research Variables: Breast cancer survivors’ descriptions of
imagery practice and experience as they created passive, active, and
Findings: Participants reported the importance of engaging passive and
active imagery, letting targeted imagery take on a life of its own, performing
homework, understanding the science, practicing, hearing imagery stories,
engaging all the senses, trusting imagery, and group interaction. Imagery
practice improved mood state.
Conclusions: When delivered by expert imagery trainers in collaboration
with oncology nurses, ERL can improve breast cancer survivors’ QOL. The
present study is one of few reports that evaluated survivors’ imagery experi-
ences from a clinical trial and produced significant QOL improvements.
Interpretation: The present study provides oncology nurses under-
standing of the psychological risks faced by breast cancer survivors after
completion of primary care and explains the critical need for post-treatment
programs for survivors dealing with post-traumatic stress disorder, depres-
sion, anxiety, or high levels of stress.
Key Points . . .
➤ After completing primary care, many cancer survivors suffer
late- and long-term effects of their cancer treatments, which
negatively affect psychological, social, vocational, and spiri-
tual well-being as well as quality of life (QOl).
➤ Psychological dysfunction and low QOl can affect physical
health, including immune function.
➤ clinically tested imagery programs can significantly improve
QOl and psychological well-being.
Lyn Freeman, PhD, is the president of Mind Matters Research in An-
chorage, AK, and an executive faculty member at Saybrook Graduate
School in San Francisco, CA; Lorenzo Cohen, PhD, is the director
of the integrative medicine program and chief of the section of inte-
grative medicine at the University of Texas M.D. Anderson Cancer
Center in Houston; Mary Stewart, MD, is a practicing oncologist and
the owner of Alaska Oncology and Hematology, LLC, in Anchorage;
Rebecca White, MD, is a family physician and the owner of Arctic
Skye Family Medicine in Palmer, AK; Judith Link, RN, is a program
director in the cancer center at Alaska Regional Hospital in Anchor-
age; J. Lynn Palmer, PhD, is a biostatistician in the Department of
Symptom Control and Palliative Care at M.D. Anderson Cancer
Center; Derek Welton is the chief technical officer and Lisa McBride,
BS, is a research professional, both at Mind Matters Research; and
Carl M. Hild, PhD, is an associate professor and director of the
Health Service Administration Program at Alaska Pacific University
in Anchorage. This research was supported by a grant from the Na-
tional Cancer Institute (1R43CA117597-01). Freeman is the owner
and Cohen is a consultant of Mind Matters Research; Stewart and
Link were compensated for their participation with money from the
grant. Mention of specific products and opinions related to those
products do not indicate or imply endorsement by the Oncology
nursing Forum or the Oncology Nursing Society. (Submitted October
2007. Accepted for publication January 31, 2008.)
Digital Object Identifier: 10.1188/08.ONF.E116-E121
OncOlOgy nursing FOrum – vOl 35, nO 6, 2008
long-term and late-term effects from their cancer treatments;
and survivors are demanding patient-centered interventions
to address the degradation in QOl caused by long-term and
late-term treatment effects. survivors described the hidden
disabilities that follow successful cancer treatment. The re-
port concluded that survivors live with “a legacy of physical,
psychological, social, vocational, spiritual, and economic
consequences” (Hewitt et al., p. xxiv). in response to Hewitt
et al. and other reports, an imagery program titled Envision
the rhythms of life© (Erl) was developed by mind mat-
ters research in Anchorage, AK, and clinically tested for its
efficacy to improve QOl in breast cancer survivors. in the
program, imagery is defined as techniques for engaging the
mind to create or reframe mental and emotional representa-
tions of objects, places, or situations perceived through and by
the senses. Techniques can range from imagery-based sugges-
tion to metaphor and storytelling (Ball, shapiro, monheim, &
Weydert, 2003; Freeman, 2004; Post-White, 2002). survivor-
ship is defined as the period of life following completion of
primary treatment (Hewitt et al.).
Thirty-four breast cancer survivors six weeks to one year
after treatment participated in the Erl stress-reduction
program. The survivors took six 2.5-hour classes over an
eight-week period. Participants identified stressful images
that they were visualizing daily, practiced replacing stressful
images with emotionally supportive ones, and created bio-
logically accurate images of optimal health. Participants also
engaged in 60-second imagery periods throughout the day
and practiced imagery for 20 minutes each night using cDs
and DvDs. measurements taken before and after the program
demonstrated that stress was significantly reduced and QOl
was statistically and clinically improved. The quantitative
findings of that study and a detailed program description are
discussed in Freeman et al. (2008).
As a result of the Erl program, the present study sought
to detail the experiences of breast cancer survivors practicing
imagery intervention. researchers wondered whether patient
descriptions could help derive QOl improvements from a
mind-body imagery program.
An estimated 182,460 women will be diagnosed with and
40,480 will die of breast cancer in 2008 (national cancer
institute, 2008). some survivors find a renewed sense of
purpose after treatment, but many others suffer ongoing loss
of health, functionality, and sense of well-being. Women
with breast cancer also are at greater risk for depression,
elevated stress, and anxiety levels (Farragher, 1998; long-
man, Braden & mishel, 1999; Oktay, 1998; Payne, Hoffman,
Theodoulou, Dosik, & massie, 1999).
Psychosocial stress can lead to immune modulation and
degrade medical and psychological outcomes, but stress-
reducing interventions can improve medical outcomes (miller
& cohen, 2001). several mind-body interventions have
reduced stress, improved mood state, and enhanced immune
function. imagery, hypnosis, and meditation in particular have
produced beneficial improvements in QOl and immune func-
tion (Bakke, Purtzer, & newton, 2002; Benson et al., 1978;
goleman & schwartz, 1976; Holden-lund, 1988; manyande
et al., 1992; miller, Fletcher, & Kabat-Zinn, 1995; solberg,
Halvorsen, sundgot-Borgen, ingjer, & Holen, 1995).
natural killer cells defend against cancer recurrence by
surveillance of the body for new neoplastic growth and ly-
sis of tumor cells (Brittenden, Heys, ross & Eremin, 1996;
locke et al., 1984). correlations exist between stress and
impaired natural killer cell function in women with breast
cancer (levy, Herberman, lippman, & D’Angelo, 1987). in
addition, increased natural killer activity has been correlated
with lower rates of breast cancer recurrence at five-year
follow-up (levy, Herberman, lippman, D’Angelo, & lee,
imagery is the foundation of most mind-body interventions,
including hypnosis, autogenic training, relaxation therapy,
biofeedback, and some meditation forms (crawford, 1982).
Patients who are fearful of hypnosis or opposed to medita-
tion for religious reasons often are comfortable with the
concept of imagery practice.
little research has described what produces successful im-
agery practice from the viewpoint of patients using imagery
to improve QOl or health outcomes. scherwitz, mcHenry,
and Herrero (2005) identified factors contributing to effec-
tive imagery engagement. The ability to engage imagery and
practitioner-patient interaction were independently associ-
ated with measures of cognitive, emotional, behavioral, and
spiritual benefit and contributed to 40% variance in patient
A case study by Freeman and Dirks (2006) reported that
imagery can reframe the cancer experience during survi-
vorship. Patients described the imagery process as a potent
skill-development tool for supporting improved mood state
and overall QOl. vivid imagery of sensations in the body,
natural environments, color, sound, taste, and smell were
related to optimal imagery practice and a sense of well-
being. With the exception of Freeman and Dirks’s study, no
research was found that evaluated the imagery experiences
of breast cancer survivors in clinical trials and produced
clinically significant improvements in QOl.
Theoretical Basis for Imagery
as a Survivor Intervention
The ability to use imagery to improve QOl and health
outcomes is based on the theory that personality and
consciousness are made up of images (Ahsen, 1968). in
addition, humans can modify the images they produce; as
imagery changes, so do emotions and behaviors. modified
emotion and behavior can lead to changes in physiology and
biochemistry as well as reduced stress and improved mood
state (Freeman, 2004).
The notion of imagery as a health modulator also is based
on the theoretical construct of the immune system as a sixth
sense. Blalock and smith (2007) posited that the immune
and nervous systems communicate in a bidirectional path-
way via a shared set of peptide and nonpeptide neurotrans-
mitters and cytokines. The messenger molecules share
common receptors and ligands between the two systems,
therefore producing a sixth sense which allows the body
to perceive pathogens, tumors, and allergens with greater
sensitivity. Blalock and smith theorized that the sixth sense
may reveal the underlying experiences and mechanisms of
Eastern and other alternative medicine practices that have
defied explanation. imagery is the basis of many alternative
and complementary medicine practices.
OncOlOgy nursing FOrum – vOl 35, nO 6, 2008
The focus group incorporated systematic procedures for data
collection, handling, and analysis (Krueger & casey, 2000). Fo-
cus group questions were reviewed in advance with three breast
cancer survivors who were volunteers from the Womenlist
support group in Anchorage, AK. input was sought concerning
set-up, lead-in comments, and the focus group questions. sug-
gestions were incorporated into the focus group format using
the Krueger method (Krueger, 1998b).
Women participating in one of two focus groups had a con-
firmed diagnosis of breast cancer and were at least six weeks
post-treatment; they had successfully completed a six-class,
eight-week-long Erl imagery program. Ten of 30 breast cancer
survivors were selected for inclusion in the focus groups using
a random numbers table.
in two separate focus groups, five participants and an in-
terviewer trained in the Krueger method sat around a table in
a classroom. The interviewer (study principal investigator)
explained that the sessions would be tape-recorded but the
names of participants would be removed during transcription.
All participants had completed the informed consent process
as approved by the Alaska regional Hospital’s institutional
review board. Participants were asked to assume a teacher
role so the interviewer could learn from their imagery experi-
ence. The interviewer explained that the shared information
would be incorporated into improving the program for future
notes were taken of key points during the session, and
the focus group was moderated with attention to participant
experience, background, and sensitivity (Krueger, 1998c).
Participants were asked to explain and then clarify their views
as they answered questions. After key points were verbalized
by the interviewer, the participants were asked to verbally
verify, clarify, or correct summary points. Participant clarifi-
cations were incorporated into the recorded outcomes. Three
questions were posed during the 1.5-hour sessions, and ad-
ditional questions were raised in each group for clarification
in response to the interview prompts (see Figure 1).
Passive imagery consists of the preconscious and conscious
images and emotions that each individual creates and recre-
ates throughout the day. The background noise and ongoing
emotional and imaginal chatter in the mind elicit significant
physical and emotional responses. Active imagery is the
purposeful engagement of emotionally supportive imagery to
modulate unpleasant and disturbing passive imagery responses.
The practice engages all of the senses, so the imagined event
is experienced vividly. Targeted imagery is the creation of a
biologic, biochemical, or physiologic process image at optimal
functionality with the goal of improving a health outcome.
Key points were compared across the two groups to identify
themes. A verifiable trail of evidence was established in the
form of patient responses for each theme identified in the
results (Krueger, 1998a). The data stream began with notes
and recordings taken during each focus group, including the
oral summary (in-room patient verification) of key points
that emerged from each group and was followed up with a
debriefing and review by the interviewer and the research
During debriefing, transcripts were reviewed and tapes
were replayed to observe voice tone and emotional response
to questions. The long-table approach was used to identify
group themes. long-table refers to cutting transcripts into
pieces as themes are identified and spread by category on a
long table (Krueger, 1998a). in the present study, numbered
comments were cut and pasted using microsoft Word on a
Dell computer. Themes and supporting evidence trails were
identified, and an outside evaluator trained in the Krueger
method reviewed the evidence trail to provide additional
input. The principal investigator and outside reviewer agreed
on the final themes.
Focus group participants represented diverse religious
and spiritual backgrounds. see Table 1 for demographics
information and cancer stage, location, and methods of
Imagery Themes: Evolution of Passive
and Active Imagery
Identify passive imagery, then engage active imagery:
Participants described how awareness of passive imagery
was necessary to create and practice active imagery for stress
reduction. Patients were surprised by how much passive
imagery affected their mood state. Becoming aware of upset-
ting passive imagery released some of its emotional effect,
and identifying upsetting and supportive passive imagery
allowed participants to engage or create active imagery to
buffer or rewrite emotional responses.
Patients required time and effort to become skilled in
identifying passive imagery. in the beginning of the study,
participants identified missed opportunities for using imag-
ery. Eventually, the participants identified passive effects that
were upsetting to them in real time. With time and practice,
the joint process (identifying negative passive effects and en-
gaging constructive active imagery) became “ingrained” and
Question 1. Describe how your passive and active imagery evolved.
Identify passive imagery; engage active imagery.•?
Practice improves mood state and relationships.•?
Homework, science, and sharing equal success.•?
Imagery stories empower transformation.•?
Question 2. Describe how your targeted imagery evolved.
Let targeted imagery take on a life of its own.•?
Targeted imagery engaged all the senses.•?
Question 3. Is there something you would like to share about your imagery
experience with future participants or with your instructor?
Let your imagery evolve uncritically.•?
Interactive sharing primes the imagery pump.•?
Figure 1. Focus Group Questions and Themes
OncOlOgy nursing FOrum – vOl 35, nO 6, 2008
“automatic,” and the process became “simple” and “pure.”
Two participants described the progression.
it was the first week or so of our doing it; it was always
after the fact. i’d look back over my day and go, “Oh
yeah! i could have practiced it there.” And so then, you
know, i did it retro, and i put myself back in that position
and i practiced it and i felt the impact of what it would
have been like. . . . i found that, over time, i got closer
to real time.
i found that [imagery] really worked, and that surprised
me. For some reason, that’s kind of hard for me to ex-
plain because it’s the field i work in [as a therapist]. But
anyway, what i was able to see in a pretty quick period
of time—two weeks—was what kinds of things really
Engaging imagery improves mood state: Patients reported
that their sense of emotional well-being enhanced noticeably
with practice. The participants became more patient and con-
structive with family members and friends, who, in turn, began
to notice and comment on how the patients had changed.
When i get a negative, i immediately think of a positive
to counteract it . . . so i’m a lot happier and i’m not hard
on people like i had been before. i realized that i don’t
bark at people, my grandkids, my husband, or anybody
like i used to. i can see a big difference.
i mean, i just focused on it, and i was dealing mostly
with my kids and their problems a lot of times this last
year. i’ve had a tendency to blow things out of propor-
tion just in reacting to them instead of thinking before
i react. And so i was able to decide that it was okay to
not just react right that second. i wouldn’t have to blow
up at them. They would say that i was a much nicer
person and it worked.
Homework plus understanding the science equals prac-
tice success: Patients identified specific motivating factors
that improved the likelihood of success with imagery. Estab-
lishing a class in which imagery homework was assigned gave
patients permission to invest time and become skilled imagery
practitioners. A necessary motivator was having clear infor-
mation on the effects of stress and how imagery works (e.g.,
the science behind mind-body effects). in addition, hearing
the experiences of others improved patients’ ability to practice
imagery. The combined factors helped patients progress with
practice and skill development.
i mean, until we were given permission through these
exercises, you know, it would have been hard . . . but
once you’ve been given permission to do that, you
don’t have to get all excited. [Other patients nodded
i just have to focus on how to use it better, to be more
organized and get the science behind it, which is very
Imagery stories empower transformation: During active
imagery training, theme-based imagery stories were read and
incorporated into imagery audio recordings that patients used
outside of class. The imagery stories, which were written
and recorded by the principal investigator, helped patients
cope by viewing disturbing events from a larger and more
constructive perspective. The story “Enlightened Teachers”
emphasized that difficult people encountered in daily life may
offer opportunities to learn about oneself. in “The Eye of the
Hurricane,” patients envisioned all of the chaos and stressors
of the world as a whirling hurricane and imagined stepping
into its calm, peaceful eye.
[“Enlightened Teacher”] was really something for me
because i have my teachers in the past. . . . But when i
started thinking that everyone i meet is being a teacher,
i realized that that’s true, everyone has something to
teach you. i realize that i listen more now than i ever
did before. And i try to learn something from everybody
and try to get the drift of what it is they are trying to
“The Eye of the Hurricane”—that really worked for
me. There are so many times in the day when i imagine
myself stepping out of the fray and into that eye. it is the
imagery that really gets me through the day. [Patients
Evolution of Targeted Imagery
Targeted imagery takes on a life of its own.
i think the thing that was most surprising to me about the
neuropeptide imagery was that [the images] took over and
they evolved themselves. i didn’t will them to change, i
didn’t ask them to change, they just rolled right down into
their next evolved state and that was surprising. it was,
it was very pleasant.
Table 1. Sample Characteristics
Stage of cancer
0 (in situ)
Location of cancer
Method of treatmenta
53.4 5.3 47–65
a Patients could opt for more than one treatment method.
N = 10
OncOlOgy nursing FOrum – vOl 35, nO 6, 2008
so my neuropeptides were all through the systems, flow-
ing with the blood. mixing with the red and the white
cells were little koi and they were all different colors . . .
where you can see all, every little scale on them. i just
called them my koi international navy, and they were just
running everywhere. i felt very protected, and they were
But a lot of it has to do with melting into the cell and
the musical notes like, “Be healthier,” and the little
notes [Patient sang four main notes from the film Close
Encounters of the Third Kind] were continually there for
awhile to get the cell’s attention. “Pay attention! We’re
here!” [Patient sang notes again.] Well, music was a way
of getting [the cell’s] attention and that was the flow, the
orchestra—all through music.
Targeted imagery must engage all the senses.
i mean, by the end i could see not just red, blue, green,
gold, and white, but i saw lots of shades of each color.
And they had that tinkling crystal noise that went along
with them and they felt kind of like sand going through
my body, kind of scratchy and it feels good kind of type
of thing. . . . They evolved into golden sparks and they
make the [sound effect] pheeeewww pheeewww pheewww
kind of sound and they actually go inside the cell.
The flavors of like cherry and lime, lemon, and all the
Advice for Future Participants
Trust your imagery.
Trust your imagery; let it evolve on its own, and don’t
judge yourself or assume you aren’t doing it “right.”
Well, [imagery has] got to be pure, and it’s got to come
from you and your heart, so you can’t have really rigid
directions with this or it wouldn’t be yours, it would be
Interactive sharing primes the imagery pump.
it is critical to bounce your imagery experience off others
in the class. sharing imagery “primes the imagery pump”
for everyone and makes the process evolve faster.
i think that’s a very good point, the triad [three-person
work groups] interactive part, that’s an imagery builder.
When you get to bounce your ideas and thought[s] off
of others, it enriches your own and it opens windows for
you that [you] really couldn’t get as good if you didn’t
have that opportunity.
in the present study, breast cancer survivors practicing
imagery demonstrated a need for a systematic approach that
identifies unhealthy passive imagery and creates healthy
active imagery to replace disturbing emotional images.
Practicing imagery improved the survivors’ mood states and
relationships. understanding the science behind why imag-
ery works was critical in motivating survivors to practice
and helping to create effective targeted imagery. imagery
practice homework also improved success. Participants used
storytelling as an imagery strategy to increase the effective-
ness of practice. Once engaged, survivors found that letting
imagery take on a life of its own without being judgmental
was helpful. Engaging all of the senses during imagery prac-
tice produced the most powerful outcomes. The survivors ad-
vised future program participants to trust imagery and share
experiences with others in the program as much as possible.
Hearing other participants describe their imagery increased
imagery creation. The participant reports have implications
for the delivery of effective programs, suggesting that an
experienced trainer with a clinical and scientific understand-
ing of psychodynamics and imagery is needed to deliver an
effective intervention. in addition, live group intervention,
which allows survivors to bounce imagery experiences off
of other participants, improves program outcomes.
Hewitt et al. (2006) revealed that cancer survivors are at
psychological and social risk for late-term and long-term
effects following cancer treatment, many of which may not
manifest until years after completion of primary care. For
example, symptoms of post-traumatic stress disorder have
been reported in 3%–4% of patients during primary care and
in 35% of patients evaluated after completion of primary care
(gurevich, Devins, & rodin, 2002; national cancer institute,
2008). Patients wait, fearful of the effects once constant medi-
cal surveillance ceases. in addition, long-term chronic effects
produced or exacerbated by cancer treatments also may mani-
fest at any time. Depression, stress, and anxiety levels can
combine to impair optimal immune function and exacerbate
other existing chronic or acute conditions (Farragher, 1998;
levy et al., 1987; longman et al., 1999; miller & cohen,
2001; Oktay, 1998; Payne et al., 1999).
Findings are limited by the lack of a control group from the
survivor population. Further verification of benefits or limita-
tions of the imagery forms used will depend on phase 2 testing
of outcomes. in addition, findings may not apply to cultural
populations not represented in the present study.
Implications for Nursing
nurses in daily practice can mitigate some of the stress
that patients with cancer experience during follow-up care.
nurses can educate themselves on the general concepts of
passive and active imagery and refer patients for appropriate
psychological care if indications of elevated post-treatment
depression, anxiety, or stress are observed. nurses can evoke
potent imagery in patients and should be mindful of the im-
agery created by their words, voice tone, body language, and
facial expressions when working with survivors who may be
psychologically vulnerable. nurses can educate colleagues
in hospital and healthcare settings about the potential for
late-term and long-term psychological and social effects
and the need to identify patients who may be at risk after
treatment. nurses can lobby for the inclusion of interven-
tion programs for survivors with long-term and late-term
psychological and social effects of cancer treatment. nurses
also can seek ways to identify patients lost to follow-up who
may be at risk. in addition, oncology nurses can team with
expert imagery trainers to deliver programs that mitigate
late-term and long-term psychological and social effects of
OncOlOgy nursing FOrum – vOl 35, nO 6, 2008 Download full-text
research has demonstrated that imagined or recalled
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immunologic effects as if the events were occurring in real
time (gruber et al., 1993; Kiecolt-glaser & glaser, 1992),
which is the basis for many of the psychological and social
late-term and long-term effects experienced by cancer sur-
vivors. The Erl imagery program’s clinical trial produced
stastically and clinically significant improvements in QOl
in breast cancer survivors (Freeman et al., 2008), suggesting
that the Erl program delivered by expert imagery trainers
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in collaboration with oncology nurses could significantly
improve survivor QOl in other populations. in addition,
participant motivation to practice is necessary for optimal
program outcomes. The present study’s themes suggest the
most effective and motivating ways to support imagery prac-
tice. Additional research is needed to assess the efficacy of
imagery programs as treatment for psychological late-term
and long-term effects of cancer treatment and to further de-
scribe patient experience.
Author Contact: lyn Freeman, PhD, can be reached at lfreeman@
gci.net, with copy to editor at OnFEditor@ons.org.